War Surgery and Medicine
CHAPTER 8 — Typhus Fever
EPIDEMIC louse-borne typhus has decimated armies and profoundly influenced campaigns over the centuries. Typhus claimed tens of thousands of Napoleon's Grand Army when he marched to Moscow. True to its traditions, typhus appeared in the first six months of the First World War, in the Balkan and Eastern areas, and subsequently in nearly all the countries and areas of Europe affected by the war, with the notable exceptions of France, Belgium, and Italy. Its scourges exceeded those of any other epidemic disease during the war, but British troops, although operating in areas where the disease was endemic, and in contact with infected allies and enemy, suffered little from typhus. Preventive measures were responsible for this freedom from the disease. Mortality was over 20 per cent in those small groups of British troops who did contract typhus. There was no typhus on Gallipoli, and there is no record of any cases of typhus among the troops of 1 NZEF, although there were outbreaks of the disease in Egypt and Palestine.
In the Second World War typhus again claimed thousands of victims on the Russian front, both Russian and German. With British troops their experience of the First World War was repeated—preventive measures again limited their cases to a small number. The full set of circumstances required for the outbreak or spread of an epidemic of typhus are lousiness, overcrowding, undernourishment, and filth. Where the care of troops and personal hygiene eliminates these conditions there is little danger of epidemic typhus, provided contacts with a poor local population are strictly limited.
Among New Zealand troops overseas in the Second World War there were only isolated cases of typhus. The greatest threat of an epidemic was to those prisoners of war in Lamsdorf camp, Germany, when some twenty cases developed among the 10,000 Allied prisoners there, but an epidemic was prevented by persuading the German authorities to allow the British medical officers to institute comprehensive control measures.
Incidence in 2 NZEF
In Egypt and other countries of the Middle East the troops of 2 NZEF were always subject to the danger of contracting typhus page 558 fever. In times of peace there were usually between two and three thousand cases of louse-borne typhus in Egypt. The poverty and miserable living conditions of the town dwellers favoured its propagation. The epidemic was seasonal, occurring annually between January and May, with its peak about April. During the war, as was also the case in the First World War, the incidence rose. In 1940 there were 4500 cases, and 9000 cases the next year. In 1942 the epidemic began as early as November, and by February 1943 the incidence had already passed the previous year's peak, and there was a sizeable epidemic in the civilian population.
For military reasons little publicity was given to the 1943 epidemic in Egypt, and most soldiers did not realise the risks involved in contacts with the native population, although general information on the control of typhus was published in 2 NZEF Orders in December 1942. In 2 NZEF there were six cases, with four deaths, at this period. The previous year there had been three cases, with two deaths, and then in October 1943 there were two cases, both of whom recovered. In 1944 and 1945 there were no New Zealand cases. The incidence was low but the mortality was high. Typhus also occurred among civilians in Syria and North Africa, and in the latter area one of our medical officers contracted it.
It is quite possible that there were cases of typhus not diagnosed and therefore not reported as such, and that the mortality was really lower. In June 1943, on the occasion of death from typhus in one of our hospitals, the Consultant Physician reported: ‘There were in hospital at this time three cases of “PUO” in which the clinical features strongly suggested mild epidemic typhus. It is apt to be forgotten that the younger the patient, the milder an attack of typhus is, as a general rule, and cases with scanty rash, or no rash at all, can quite easily be missed. The completed temperature chart, when the disease is over, will often give a clue to what the correct diagnosis was, and it is not too late even then to get a positive Weil-Felix reaction.’
The care of troops in the provision of good living conditions, adequate ablution, shower and laundry facilities, and a high standard of personal cleanliness maintained by the troops, reduced louse infestation to a minimum. There was a possible chance of infection by inhalation of dust contaminated with dry louse excreta, and avoidance of close association with natives was important.
Native labourers employed in Maadi base camp were compulsorily showered and their clothing disinfected each week, an elaborate delousing station being built at the entrance to the camp and controlled by the Base Hygiene Section.page 559
In June 1943 anti-typhus vaccine became available to 2 NZEF. There was insufficient vaccine available at first to immunise the whole of 2 NZEF, so priority in this form of protection was given to hospital staffs who might have been exposed to risks in nursing patients, and to hygiene personnel whose work brought them into contact with lousy natives. As more vaccine was supplied the whole force was inoculated. Most were inoculated prior to their move to Italy in October 1943 with three doses at weekly intervals, and ‘booster’ doses were given in Italy every six months.
Early in 1943 the Consultant Physician 2 NZEF, Colonel Boyd, was asked by the DMS 2 NZEF to investigate the typhus epidemic as far as circumstances would permit, and he was fortunate in being able to make an extensive tour with the Director-General of Health in the Egyptian Government, covering many native villages around Cairo, Benha, Tanta and Alexandria. They visited the isolation hospitals and numerous emergency tented hospitals, and out of some thousand cases personally examined close on four hundred.
The clinical features of these cases were very similar to those encountered amongst the few cases admitted to New Zealand General Hospitals. In many cases there is a prodromal period of slight pyrexia and malaise lasting twenty-four to forty-eight hours. The temperature then drops to normal and the patient feels perfectly fit. Some twenty-four to thirty-six hours later the true fever develops.
The onset is sudden, the temperature rising rapidly to fairly high levels, 102 to 105 degrees F., and the patient at once feels very ill. He has generalised aches and pains, and often, but not always, some degree of headache, usually frontal. To begin with, the pulse is usually in keeping with the temperature, but later becomes relatively slow. By the second or third day the face is congested and the eyes suffused. The tongue soon becomes dry and coated; by the eighth or ninth day it is almost diagnostic of the disease—dry with a dirty brown or blackish fur, and tremulous. The patient at this stage is usually unable to protrude it, and his speech is thick and indistinct. Most patients are dull or stupid by the second day and delirium may occur at any stage.
The rash appears on the fourth or fifth day, first on the sides of the chest and abdomen, and quickly spreads over the trunk and limbs. It consists of dirty pink blotches of varying size and tiny punctate dark red petechiae. By the ninth or tenth day most patients are quite deaf, and the limbs are tremulous. The more page 560 toxic case lapses into a ‘typhoid’ state, like that of typhoid fever, but without the tumid abdomen. The spleen is palpably enlarged in only 25 per cent of cases.
The temperature drops about the twelfth to fourteenth day, usually by a rapid lysis. Numerous variations have been described in the type of temperature chart, but they are of little or no diagnostic or prognostic significance.
The disease may be suspected, but cannot be diagnosed with certainty till the rash appears. The white blood count gives no help, and the Weil-Felix reaction gives no help at the time it is really wanted.
There was during the war no specific treatment. Good nursing was the main essential. Sulphonamides and penicillin were useful for secondary infections but seemed to have no effect on the disease itself.
In Italy the New Zealand Division's anti-typhus measures were increased. The mobile shower unit of 4 Field Hygiene Company was busily engaged in showering an average of 450 men a day, and the company's disinfestor was used for the disinfestation of clothing and blankets, while the Mobile Laundry and Bath Unit functioned to capacity. The establishment of 4 Field Hygiene Company was revised in the summer of 1944 to include the anti-malaria control units, with the provision that they become anti-typhus sections in winter when there was a threat of typhus. In the winter of 1944 these sections carried out a limited spraying of divisional sleeping quarters with DDT, and 4 Field Hygiene Company constructed a power dusting unit for the dusting of all showered soldiers and their clothing. Supplies of DDT-impregnated shirts became available and were issued to troops more likely to be exposed to risk of infection, while arrangements were made with the Laundry Unit for the dusting of blankets before re-issue. Anti-louse powders were readily available. Louse infestation in the Division increased in the winter of 1944, but no cases of typhus occurred among New Zealand troops during the time they were in Italy.
There was an epidemic of typhus among civilians in Naples from December 1943 to February 1944, but it was speedily terminated by rigorous methods of control. At the time the city was placed out of bounds to New Zealand troops who were in the area prior to attacking Cassino, but members of other forces on duty in the city escaped infection by carrying out adequate preventive measures. There were 1600 civilian cases but no British Army cases other than one deserter.
The lesson learned in Naples was that, even under conditions ideal for the spread of typhus such as existed in Naples, typhus page 561 can be quickly and effectively controlled by the energetic search for cases and contacts, the large-scale use of insecticide powders applied inside clothing by dust guns, the enforcement of routine preventive measures such as restriction of travel, closure of public places, and intensive propaganda which encouraged a lousy population to crowd into dusting stations. An army, even when employing large numbers of civilians, can live and work in an overcrowded, typhus-ridden city with freedom from infection, provided preventive measures are conscientiously carried out.
One of the powder insecticides used was AL 63, containing derris and naphthalene, and it was found effective for louse control but DDT (dichlor-diphenyl-trichlorethane) was found to be superior by reason of its more persistent action and also because it was non-irritating.
In the South-West Pacific, as in South-East Asia, there was a danger of scrub typhus, especially where troops were in contact with the Japanese. This form of typhus, also called tsutsugamushi disease, is mite-borne, and the medical services with the New Zealand troops in the Solomon Islands were on the lookout for its appearance, but fortunately no cases developed during the campaign. This disease is not of the epidemic type, but it caused unexpected trouble among troops in New Guinea and Burma.